0303-149 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date.
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I, hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
(�) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business ,& Professionals Code). ,
( ) 'I, as owner of'the,,,property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). r
() I'am exempt under Section B&P C . for this reason
Date t G: l ; • Signature of Owner (-
u WORKER'S COMPENSATION DECLARATION
I hereby .affirm under -penalty of perjury one ofthe following declarations:
( )` I have and will maintain a certificate of consent to self'insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of tfie work for which this permit is, issued.
I. ( )' I have and will maintain workers' compenation insurance, as required by
,Section 3700 of the Labor Code, for the performance of the work for which this
pe�mit'is issued. My workers' compensation insurance carrier & policy no. are:
Camer Policy No.
(This section need not be completed if.the permit valuation is for $100.00 or less).
( ); I certify that in the performance of. the work for which this permit is issued,
hshall"not employ any. person' in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I !shall forthwith'comply with those provisions.
Date' fi Applicant _ .' y e•
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code,?interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to • the conditions and restrictions set forth on his y
application.
k'
1. Each person upon whose behalf this application is made & each person at F
whose request and for whose benefit work is performed under or pursuant to
any permit issued as'a result of this applicaton agrees to, & shall, indemnify
&-hold.harmless the ,City. of.:La Quinta, its officers, agents and employees
2. Any permit issued as'a result of this application becomes null'and void if t;
work is not commenced within 180 days from date of issuance of such t
" permit, or cessation of.work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes. s ,
Signature (Owner/Aaent)y';'z'u s 'i'r'' -7�4 '- Date loll +
R�fry�
PERMIT #
BUILDING PERMIT-
jJrf
DATE 1 • VALUATION LOT'- " 1)203—J.49;,TRACT
.. GY313a1dt _..% i4,.4TSJ
JOB SITE
APN '
ADDRESS
46-49.5 WASHING -TOR ISMM'
OWNER
CONTRACTOR/DESIGNER/EN (NEER
V
MOM - 8't3RD1,3t
46.495 WASI fi'Z TON Ulf'
46-4•95 AMSE i' IDDIT
ljQb.?'Drrt, C,A. -92253
LkQtWfA (-I A 922M
NC)564-46154 M.IX
USE OF PERMIT
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`CIVY®FLAQUIN
AFWANCEMPT
,r
fIECEIPT
DATE-- /r'
Bl: /{d ,:,
DATE FINALED
INSPECTOR r
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings =Xa
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
_
Final 3 -
Gas Piping
I PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
71f I's P�l,2y 7o S�+�w
GOLDEN BLANKET POLICY
As AA SM Dt;.✓ DECLARATIONS
Non -Assessable
Page 1 of 4
These Declarations are a part of the policy named above and identified by policy number below. They
supersede any Declarations issued earlier. Your Golden Blanket Policy will provide the insurance described
in this policy in return for the premium and compliance with all applicable policy provisions. See policy for
details regarding the other coverages and additional coverage options.
Policy_Number. _ Policyholder:
72 04 MP'166801 J (Named Insured)
�- VERONICA SOPTICH
Issued: 46495 WASHINGTON
STREET
MAR 09, 2001 LA QUINTA CA 92253-2038
Policy Period From:
MAY 02, 2001 to MAY 02, 2002 b only if the required premium for this period has been paid, and only
for annual renewal 'per-iods-if•premiums-areypaid as required. Each period begins and ends at 12: 01 A. M.
standard time at the Residence Premises.
The Following Change(s) Have Been Made To Your Policy:
The limit of liability for Section I Coverage A Dwelling is revised.
Limits of Liability for Policy Option Water Backup is changed.
Policy Option L Protection Device Credit is added.
Residence Premises Information:
VERONICA SOPTICH ONE FAMILY
46495 WASHINGTON FRAME DWELLING
STREET YEAR OF CONSTRUCTION 1973
LA QUINTA
CA 92253-2038
SECTION
Property Coverages
COVE RAG E -A -DWELLING
REPLACEMENT COST PLUS
LOSS SETTLEMENT
COVERAGE -B=OTHER STRUCTURES
COVERAGE -C-PERSONAL PROPERTY
REPLACEMENT COST COVERAGE
COVERAGE-D=LOSS OF USE .
SECTION II
Liability Coverages
COVE RAG E -E -PERSONAL LIABILITY
FOR EACH OCCURRENCE:
PROPERTY DAMAGE AND
BODILY INJURY
COVERAGE -F -MEDICAL PAYMENTS
TO OTHERS EACH PERSON
H5300
e
PROTECTION CLASS 4
INSIDE PROTECTED AREA
WITHIN 1000 FT FROM HYDRANT
WITHIN 5 MILES FROM FIRE DEPT
FIRE DISTRICT 0081
PROTECTION TERRITORY 079
Limits Of Liability Deductible: $500 ALL PERILS
r
$ 149,500 In case of a loss under Section I, we
cover only that part of each loss over the
INCLUDED deductible stated.
$ 14,950
$ 112,125
INCLUDED
$ 149,500
Limits Of Liability
$ 300,000
$ 5,000
0
to
LO
0
O
'GOLDEN.: BLANKET P
OL'ICY .
DECLARATIONS
_ Non Assessable
! 'Policy Number: Policyholder: Page 3 of 4
72 04 MP; 166801 (Named Insured) .
VERONICA SOPTICH'
Issued:" `, ' ' ` ^ , _ Policy Period From:
MAR 09�, .2001 '' 'MAY 02, 2001 TO MAY02, -2002
PREMIUM SUMMARY
j Premium Based On ' s 'T` Premium Amount
POLICY PREMIUM �• rt y Y �, s, f ,. ;
WORKERS COMPENSATION $' t•. -•430.00
WATER BACKUP.. �` $ 3.00 r
$ 20.00 •
Annual Renewal Premium
$ -453.00
Annual Renewal Premium Includes Discounts For: `
HOME PROTECTIVE DEVICE
,}
FORMS and ENDORSEMENTS. MADE PART•OF POLICY
Fire 27.02.Golden:Blanket-Home
Fire 2530 ✓,_ *
s Policy
Workers Compensationyand.Employers'
Fire 3090
Liabilit
Insurance Endorsement y
Fire 3191 A
Lender's Loss Payable Endorsement ,
Amendatory Endorsement
Fire 2800.
Fire 3037 -A -,Amendatory
y Water Back Up,of Sewers or Drains Endorsement
'
Cancellation, Renewal and Nonrenewal
Fire 3381
J Endorsement
Building Ordinance or Law
ADDITIONAL INTERESTS'
`
µ
FIRST MORTGAGEE '•
GMAC MORTGAGE CORP
DBA DITECH COM t,. '
ITS SUCC &OR ASSIGNS:.r
SUITE 150
3200 PARK CENTER -DR t
COSTA MESA CA 92626-1982
LOAN #652114028. ''
Issued By:� NATIONWIDE MUTUAL FIRE INSURANCE'COMPANY,• Home Office Columbus, Ohio
Countersigned At: SACRAMENTO, CA By; W. D. SMITH
Prior Declaration Issued:-JUL 26, 2000 `.
t yy
,GOLDEN BLANKET POLICY DECLARATIONS
Page 2 of 4
PERSONAL PROPERTY—SPECIAL LIMITS OF LIABILITY
The special limits shown below for each category is the total limit for each loss for all property in that
category. They do not increase the Coverage— C —Personal Property limits of liability. See Policy for details
regarding the Special Limits of Liability. These limits included
are
in the basic Policy premium.
Theft Losses Only
Category
Limits of Liability
JEWELRY, WATCHES AND FURS
OPTION A BELOW
CAMERAS
GUNS
$ 1,000
TOOLS
$ 1 1,000 000
SILVERWARE
, $ 2, 500
All Covered Losses
Category'
Limits of Liability
6
MONEY
SECURITIES
200
$ 1,000
WATERCRAFT
TRAILERS
$ 1,000
MANUSCRIPT ,,
000
$ 1, 000
COMPUTERS
BUSINESS PROPERTY
$ 3,5000
00
OTHER COVERAGES/OPTIONS APPLICABLE
See Policy or Endorsements for details regarding the Other Coverages and Options that apply to your policy.
Other Coverages
Limits of Liability
INFLATION PROTECTION
APPLIES
BOECKH INDEX 599.6
ACCIDENTAL DEATH BENEFIT
EACH CHILD
$ 500
EACH ADULT
FIRE DEPARTMENT SERVICE CHARGE
5000
$ 2,00
CREDIT CARD - FORGERY
$ 1,000
Options Applicable
OPTION -A -JEWELRY, WATCHES AND FURS
$ 2,500
OPTION -L -PROTECTIVE DEVICE CREDIT f
"APPLIES
LOCAL FIRE OR SMOKE ALARM SYSTEMS
FIRE EXTINGUISHERS
DEADBOLT LOCKS ON ALL EXTERIOR ENTRYWAYS
ORDINANCE OR LAW 10% OF COVERAGE A
APPLIES
WORKERS COMPENSATION
APPLIES
PART TIME OR OCCASIONAL EMPLOYEE
WATER BACK UP
APPLIES
SPECIAL PROVISIONS
YOUR PROPERTY IS NOT EXPOSED TO BRUSH FIRE HAZARD.
"a"i`.'�'�!^�`W'�":'►'+-'r _ _.,��r-•:w�,;r,.,�ww...77
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�1 Page No. -of Pages
74-691 Sweet Well Road
THE Thousand Palms, CA 92276
PART1VERSHIP a. Jean-Pierre / Jean -Guy
Phone (760) 275-4640 • (760) 275-6017
Remodeling Painting • New Construction Fax (760) 343-0119
"EXPERIENCE makes the DIFFERENCE www.PelletierPartnership.com • E-mail: GUYPELL@aol.com
Aluma-Lattice® PATIO COVERS j License No. 260484 • 32 Years Experience
PROPOSAL SUBMITT D TO I PHONE DATE
k
STREET O JOB NAME
zw -7-A
CITY, STATE dhd ZIP'COD /lam I eJOB LOCATION
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P PI'A#tASP hereby to furnish material and labor complete in accordance with specifications below, for the sum of:
dollars ($ C/ •' ).
Payment to be made as follows: /
6,4rrw 00
All material is guaranteed to�ba as specified. All work to be completed in a workmanlike .
manner according to standard practices. Any alteration or deviation,.from specifications Authorized
below involving extra costs will be`executed only upon written oFders, and will,become an Signature /� l
extra charge over and .above the estimate: All agreements contingent upon strikes,'
accidents or delays beyond our control. Owner to carry fire, tornado and other necessary°' �a Note: Thi proposal may be
insurance. Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within days.
Fate
tThe above prices, specificationstions are satisfactory and are hereby accepted. You are authorizedSignaturework as specified. Payment will be'made as outlinedabove.
ceptance: '� Signature
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���. �� ( .
t
.N..T
Page.No: of. Pages
74-691 Sweet Well'Road
i P LI.TtLpR:
Thousand Palms, CA 92276
HIP Jean-Pierre / Jean -Guy
Remodeling Painting • Ne Construgrrion Phone (760) 275-4640 • (760)275-6017
Pay (76n) IAL -n110
"EXPERIENCE makes the .DIFFERENCE", .',�']"www.PelletierPartnerst ip.com'o E-mail:'GUYPELL@aol.com'.'
umd-Lattice®PATIO COVERS : License No. 260484. 32 Years Experience
PROPOSALSUB TO
PHONE '. DATE
STREET
�r
JOB NAME.
CITY, STATE fnd Z OD
JOB LOCATION'
[SD + � /J -
ARCHITECT
DATE OF PLANS
JOB PHONE
We hereby it specifications and estimate r
.
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t?. nY11059'. herebyto:furnish material- and 'iabo'r=complete'in accordance:withspecifications below, for the sum of:
dollars
Payment to be made as follows:'
All material is guaranteed to be as specified. All work -to be completed Ina wke
orkman
manner according. to standard,praoices.:Any ilteratlon-or deviatidn.!MT specifications Authorized
below inWIving -extra costs will be'executod only uponwritien ofders, and wlll:become'ah Signature
extra charge over and'.aboVe the estimate: All agreements contingent upon strikes, ' ?.
accidents or delays beyond.cur;coritrol. Owner to cany fire; iomado and other necessary "' Note: Thi oposal maybe
M,u„� • ��, •• ,1mv- wa iuny cuveruu uy vvurKman s aompensanon Insurance. wiuiularwrr uy us n nut acceptea wimm days.l
VtattP'P II The above prices, specification's
and conditions are satisfactory and are hereby accepted, You are authorized .$fgnature
to do the work as specified. Payment will befmade a. 'outlined above.
a air
'Date of Acceptance: - Signature /
OWNER/BUILDER INFORMATION
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the property'
improvements specified.
For your protection you should be aware that as "Owner/ Builder" you are the responsible party of record on such a
permit. Building permits are not required to be signed by property owners unless they are personally performing their
own work. If your work is being performed by someone other than yourself, you may protect yourself from possible
liability if that person applies'for the proper permit in his or her name:
�r
Contractors are required by law to be licensed and bonded by the State of California and to have a business license
from the City or County. They are alsorequired by law to put their license number on all permits for which they,
apply.
If you plan to do. your own work, with the exception of various trades that you plan to subcontract, you should be
aware of the following information for yourbenefit and protection:
If you employ or otherwise.engage any persons other than your immediate family, and the work (including materials
and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or
subcontractors, then you may be an employer:
If you are an employer, you must register.with,the State and Federal Government as an employer and you are subject
to several obligations including State and Federal income tax withholding, federal . social _ security taxes, worker's
compensation insurance, disability insurance costs and unemploymeni compensation contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with
respect -to worker's compensation insurance.
For more specific information about your obligations under, Federal Law, contact the Internal Revenue Service (and, if
you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under State
Law, contact the Department of Benefit Payments and the Division of Industrial Accidents. .
If the structure is intended for sale, property- owners who are not licensed contractors are allowed to perform their
work personally or through, their own employees, without a licensed contractor or subcontractor, only under limited
conditions.
A frequent practice of,unlicensed persons professing to be contractors is to secure an "Owner/ Builder" building
permit, erroneously implying that the property owner is providing his or her own labor and material personally.
Building permits are not required to be signed by.. property _owners unless they are performing 'their own work
personally.
Information about licensed contractors maybe obtained by contacting the Contractors' State License Board in your
community or at 1020 N: Strem-Sacramento-,, California 95814----
Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of
these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico
La Quinta,CA 92253
(760)7 -7012
FAX: ( 60) 777-7011
OWNER'S SIGNATUR /DATE
�f s �S67-0 C
PROPERTYADDRESS
Site Requirements: for:
Interior, Lot
SIDE YARD: S Feet REAR YARD: 10 Feet
Minimum, Each Side Minimum
I
AREA M
::--LANMSCAPED
FRONT YARD•
20 Feet PROPERTY
Minimum LINES
CITY OF LA QUINTA i
BUILDING & SAFETY DEPT.
'APPROVED CURB LINE
FOR CONSTRUCTION
DA �i a2 y 5 -
i